Background: A significant component of the therapeutic effect of allogeneic hematopoietic stem cell transplantation (alloHSCT) is mediated by lymphocytes, particularly T cells, in the allograft (i.e. graft-versus-tumor [GVT] effect). However, the degree to which GVT effect contributes to the efficacy of alloHSCT differs significantly between various malignancies. In patients with extremely chemotherapy-refractory tumors and/or tumors with rapid growth kinetics, the GVT effect may be insufficiently potent to be detectable because the tumor had developed resistant mechanism which inhibit or are lss susceptible to to GVT effects or the tumor growth rate exceeds the ability of the immune effect to eliminate disease. The susceptibility of various malignancies to the GVT effect most likely reflects the biologic characteristics that are unique to that respective disease, such as growth rate and antigen expression. Due to this significant heterogeneity, we initially elected to focus our research efforts, relative to GVT effects, on a single disease group, B cell malignancies. More recent efforts have been focused on pre-clinical studies in myeloid malignancies. NCI Strategic Plan Relevance: Develop Effective and Efficient Treatments Project Goals: 1. Develop novel treatment strategies for patients with persistent or recurrent disease after allogeneic adoptive cellular therapy The management and treatment of relapse or progression of disease following alloHSCT is a significant clinical problem. Treatment options are extremely limited for patients who experience disease recurrence or progression following alloHSCT. These options include the withdrawal of immune suppression and/or the administration of donor lymphocyte infusions (DLI), the use of conventional therapeutic treatments for the respective disease, or a second alloHSCT. With the exception of chronic phase chronic myelogenous leukemia, these treatments only benefit a minority of patients, the benefits are often transient, and the treatments are associated with a high degree of morbidity, particularly GVHD. In addition, many of these therapies are not applicable to patients in whom disease recurs while experiencing active GVHD. After alloHSCT, lymphocytes are found infiltrating residual tumor. It is likely that these cells are of donor origin and may exhibit enhanced antigen specificity and tumor-specific homing. Compared to donor peripheral blood lymphocytes or to tumor-infiltrating lymphocytes in non-transplant patients, the lymphocytes found in tumor after alloHSCT may have a higher potential for disease control. It was our hypothesis that lymphocytes found in tumor after alloHSCT are of donor origin, and because they are tumor-derived, they may be tumor-specific in their homing and antigen specificity characteristics. Further, activation and expansion of these cells through CD3/CD28 costimulation may yield a more effective form of cell therapy after alloHSCT, with enhanced GVT effects and less GVHD. Pre-clinical studies of the costimulation technique were evaluated using autologous lymphocytes derived from a variety of tumor types (i.e. from anonymous patients having tumor resected for clinical indications). A two-week culture with CD3/CD28 costimulation resulted in up to 30-fold increase in T cell numbers. Several important observations were made during these pre-clinical studies. The first was the addition of tumor to the culture resulted in 3- to 10-fold better yield of T cells as compared to cultures without tumor cells, suggesting the possibility of antigen-driven expansion. Second, an additional round of cell costimulation yielded additional 10-fold expansion. Third, in cultures containing tumor cells, tumor cell death was observed, suggesting either T-cell mediated killing and/or the culture conditions were not conducive to tumor cell growth. Fourth, costimulation and culture yielded a cell production with an effector memory cell phenotype and minimal numbers of cells with a T-regulatory phenotype. Based on these pre-clinical data, a protocol, 07-C-0064, for the clinical use of allogeneic TDL for treatment of B-cell malignancies which have relapsed after alloHSCT was written and and subsequently received FDA IND approval in January 2007. The primary objective of the study is to evaluate the feasibility of administering ex-vivo costimulated/expanded TDL in patients with persistent or recurrent BCL following alloHSCT. Specific feasibility aims include the consistent isolation, costimulation and expansion of clinically relevant numbers of TDL from resected tumor specimens. The other primary aim is to determine the safety of administering TDL relative to infusion toxicities and hyperacute GVHD. The protocol has a number of correlative studies which include both tumor and lymphocyte characterization prior to culture and characterization of the immune phenotypic and functional characteristics of TDL after culture. In addition attempts will be made at target antigen discovery, through SEREX-related methods for the identification of tumor-reactive donor T cell targets. Nine patients have been enrolled onto this this clinical trial. We have have been able to demonstate teh feasibility and safety of this approach. there have been two objective responses. We have broadened the application of thsi approach to utilize bone marrow with tumor invovlement. Similar to pre-clinical results with lymph nodes we were able to demonstrate that clinical grade and number T lymphocytes, free of relevant tumor contamination could be generated from small (10-20 ml) aliquots. Based on these results with B-lymphoid malignancies, we have recently completed pre-clinical studies using bone marrow samples from patients with myeloid malignancies (AML and MDS). These studies demonstrated that lymphocytes with effector phenotypes could be generated to clinically significant numbers fro of leukemic contamination from small marrow aliquots. Currently an application for an IND is in preparation with subsequent plans to implement two clinical protocols for relapsed AML/MDS in the pre- and post-transplant settings, respectively. 2. Develop a trans-NIH multidisciplinary clinical research program addressing the problem of disease relapse after allogeneic stem cell transplantation. In major collaboration with POB (A Wayne, T Fry) we have initiated a major effort to study the biology, natural history, and to treat relapsed hematologic malignancies after allogeneic stem cell transplantation. these efforts include the establishment of a relapse working group (Bishop, Wayne and Hardy) which meets regularly to coordinate all of these efforts. There is a monthly relapse tumor board which bring together investigators from multiple disciplines (e.g. pathology, radiology, radiation oncology, medical oncology, etc..) from within CCR and across NIH (NHLBI, CC). A formal relapse clinic has been established which utilizes all CCR protocols for which patients with relapsed disease after allogeneic HSCT aare eligible. A natural history protocol, which studies tumor biology and patient characteristics has been written and it is anticipated that it will be submitted to the IRB before the end of 2010.